Update Clinical Record

Please help us to keep our clinical records up to date by providing the information below.

PLEASE NOTE THIS IS NOT FOR CHANGE OF NAME – please click here for the Change of Details page where you can download the relevant form for these changes and bring it to reception with the required ID

1 Your Details

Title

First Name

Surname

Date of Birth

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

If you have your NHS Number please provide it

2 Your Contact Details

Email Address

Home Phone Number

Mobile Phone Number

3 Physical Attributes

Your Height

Measurement is in...

Your Weight

Measurement is in...

Waist Measurement

Measurement is in...

4Lifestyle Choices

Do you currently smoke?

If you do smoke, how many cigarettes, on average, do you smoke in a day?

Do you drink alchohol?

If you do drink, how many units, on average, do you drink in a week?

5 Additional Information

Are you a carer?

Are you allergic to any medications?

What is your ethnicity?

What is your first language?

Other Information

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toShotfield Medical Practice
•
Shotfield, Wallington, Surrey, SM6 0HY.

Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.